- When there is concern for physical abuse, the physical examination should be completed with the child undressed (in a gown), with specific attention to the skin, scalp and fontanel, mouth and oral cavity (including frena), ears, genitalia, and growth chart.
- Any injury in a preambulatory child, including bruises, mouth injuries, fractures, and intracranial or abdominal injury, should raise concern for abuse.
- The “TEN 4” rule: bruising of the Torso, Ears, or Neck in children <4 years old and any bruising in children <4 months old should raise concern.
- Radiographic skeletal survey should be performed using proper technique for children <2 years old with concern for abuse. Repeating the skeletal survey 2–3 weeks later can identify additional fractures that were not seen initially.
- Young (<2 years old) siblings and household contacts of abused children should be examined for abusive injuries and undergo skeletal survey.
- Infants evaluated for physical abuse may benefit from neuroimaging even if they don’t have neurological symptoms.
- Retinal examination is indicated for children with concern for abusive head trauma but may not be indicated for children without intracranial injury.
- Health care providers with a reasonable suspicion of physical abuse have a legal mandate to report their concern to child protective services.
